How to Submit an Insurance Claim
Non Student-athletes
  1. Obtain a Student Assurance Claim form by going to http://www.sas-mn.com/claimform_download.html, then click on the claim form tab OR you may contact Donna Gerlach, RN, at (605) 995-2957, or stop at her office in Rollins Campus Center.
  2. Complete the top information section of the claim form and questions one through 10. Be sure to address all questions within the numbered area. Sign and date the bottom of the form.
  3. After completing the claim form, attach a copy of the coded bill(s) from your medical provider(s) for services rendered. If submitting pharmaceutical bill(s), include a copy of the prescription receipt attached to your medication with name of medication, directions for use and cost, along with a copy of the cash register receipt.
  4. You may self submit this claim to Student Assurance Services, INC., P.O. Box 196, Stillwater, MN 55082-0196, or you may turn in the completed claim form along with all of the required information to Donna Gerlach, 1200 West University, Box 926, Mitchell, SD 57301.
  5. If you have questions, contact Donna Gerlach, RN, at dogerlac@dwu.edu or call (605) 995-2957.

Athletes
  1. After your primary insurance has been billed and processed, the remaining out-of-pocket expenses that you incurred from your athletic injury may be submitted to your secondary insurance provided through Student Assurance Services.
  2. Obtain a Student Assurance Claim form by going to http://www.sas-mn.com/claimform_download.html and click on the claim form tab OR you may contact Jarod Guthmiller, head athletic trainer at (605) 995-2144, or go to his office located in the Christian Family Recreation/Wellness Center.
  3. Complete the top informational section of the claim form and questions one through 10 of the Student Assurance Claim form. Be sure to address all questions within the numbered area. Sign and date the bottom of the form.
  4. Ask your medical provider if their facility will bill the secondary Student Assurance. If the facility does bill secondary insurance, let them proceed with the claim. If they do not bill secondary insurance, return all of the following required information to Jarod Guthmiller, 1200 West University Ave., Box 912, Mitchell, SD 57301.
    • The completed Student Assurance Claim form, signed and dated
    • A copy of your private insurance’s explanation of benefits (EOB)
    • A coded copy of the medical bill(s) or HICFA form(s) from all of your medical providers
    • Prescription receipts if applicable
  5. In house secondary insurance through Student Assurance Services will not be billable if the athlete’s primary insurance is not in effect at the time of the injury.
1200 W. University Ave., Mitchell, SD 57301
800-333-8506



Copyright © 2014 Dakota Wesleyan University.
All rights reserved.




Dakota Wesleyan University was named to the 2013 President's Higher Education Community Service Honor Roll. This designation is the highest honor a college or university can receive for its commitment to volunteering, service-learning and civic engagement.
Dakota Wesleyan University is proudly affiliated with the Dakotas Conference of the United Methodist Church. Members of any and all faiths are welcome and encouraged to experience an education based on learning, leadership, faith and service.
Dakota Wesleyan University has been honored as a College of Distinction through demonstration of excellence in these areas: engaged students, great teaching, vibrant communities and successful outcomes.
The Chronicle of Higher Education named Dakota Wesleyan University one of the “Great Colleges to Work For®” for 2014-2015. DWU won honors in three categories: facilities, workspace and security, and supervisor/department chair relationship.
Dakota Wesleyan University
1200 W. University Ave
Mitchell, SD 57301
800-333-8506
Copyright © 2014 Dakota Wesleyan University
605-995-2600
View Mobile Site
Sitemap
South Dakota Website Design and Development